Mother Baby Unit

Well I just finished the first two weeks of my pediatric rotation and I had the wonderful opportunity to be in the newborn nursery, evaluating newborns in the first few days of their lives. I worked with one intern, and an attending physician. The intern was a first year resident, and we had three different attendings (depending on the day). The attending physicians have been pediatricians for many many years, and taught us what we need to know about taking care of healthy newborns. I have to admit that I have cheated a bit in this area by having already experienced birth, breast feeding, and the exhausting newborn period. Even though I have been around newborns, my hand was still shaking the first time I listened to a newborn's heartbeat last Monday. After ten days of newborn exams though, I feel confident about checking out these new little additions to the human race.

So what does the newborn exam entail? You would be surprised to know all the possible abnormalities that physicians are checking for in the first exam. Unfortunately for the parents and for the little baby, getting naked and having doctors look and examine everything so closely can be disconcerting, especially for the newborn, who is much more happier all swaddled up in a position similar to the one he or she just spent 8 or 9 months in. It's amazing the power of the swaddle - a screaming baby will quiet immediately with this magic trick. The attendings tell me that it works for the first 3 months of life...wish I knew that when I was a young mom!

But I am getting ahead of myself. This is what a newborn exam is like, and what I learned in the past two weeks to become proficient at: We enter the room, introduce ourselves to the family as the pediatric team, and ask if we can take a look at their baby. Given that OHSU is a teaching hospital, and that mom is also considered a patient by the OB/GYN team of physicians, the family is interrupted a lot in the first few days after the baby is born. The nurse comes in to check vitals on the mom and baby every 4 or 8 hours, the lactation consultant comes in to help the mom with breast feeding, the social worker comes in to make sure mom and dad have adequate support at home, not to mention all the students - nursing, and medical students like me, who are trying to learn the skills of exam and taking patient histories.

So after the parents have reluctantly let us remove the little one from their arms, or worse, we wake them up from a much needed nap, we examine the baby in a crib right next to mom, explaining along the way what we are checking for and why. That way if the baby starts screaming, the parents know that we are not torturing their child, although there is a special trick we do to try to calm the baby. We glove up, and put one of our fingers in the baby's mouth. Not only does this calm the baby, who inherently has a sucking reflex after birth both for comfort and for feeding purposes, but it also allows us to check the palate for any abnormalities, such as cleft or extra teeth.

The head to toe exam includes examining the head for birth trauma. There can be swelling or bruising associated with a normal vaginal delivery, or the use of a vacuum or forceps to help the baby out. Other trauma from birth can include shoulder dislocation, especially if the baby is a big one. We check all the skin surfaces, to note any birth marks, or abnormal skin rashes that would prompt us to do a further evaluation for infection. Newborn babies skin vary depending on their gestational age (how long they were in the uterus). Early babies have soft smooth skin, while babies who were born late, after the 40 week due date, have more dry and wrinkly skin. We reassure the parents about the normal skin changes that are seen in newborn babies - rashes and little bumps that can look bad but are totally normal.

We listen to the heart (to check for murmurs), the lungs, and the guts (to make sure the digestive system is working). We check their anus to make sure it's open, and the boy's penis to make sure the meatus (hole where the urine comes out) is in the right place. We look at the feet, hands, and turn the baby over to check the back and spine. For feet we are looking for a reflex where they curl their toes around our finger (they will loose this "monkey" reflex in a few months), for the right number and separate toes (we had one baby born with only three toes on one foot, and several others that had what's called syndactly - webbing between two toes). We also check the hands to check for what's called a simian crease (one connecting horizontal palmar line instead of two that can be a marker of Downs syndrome). When we examine the spine we are looking for any sacral dimples that are abnormal (they may be connected to the spinal canal or indicate an underlying abnormality of the canal). We did have one baby with a little dimple and a heaped up layer of skin below the dimple that looked unusual enough to the attending that she ordered an ultrasound which came back showing a cyst in the spinal canal. We then called pediatric neurosurgery to evaluate the imaging and let the family know what to do next.

99.9% of the babies I spent the last two weeks with were completely normal, just getting adjusted to extra-uterine life. A few required some interventions, and one of the reasons we make the babies stay for 48 hours is that we want to monitor for possible infection, as well as for jaundice. Jaundice is yellowing of the skin that normally occurs in newborns and is a result of the liver being a little immature in it's ability to break down red blood cell and eliminate the pigment called bilirubin. Although bilirubin depositing in the newborn's skin is normal, we monitor the levels to make sure that they don't get too high and cause any damage to the brain. If we find that levels are too high, then we put the baby under UV lights, which helps to eliminate the excess bilirubin. If lights are needed, the baby is put in a warm incubator that has lights above, and the baby's eyes are covered. Once the lab values show an appropriately low level of bilirubin in the blood, we let the family go home, although we also make sure that they have a follow up appointment with a pediatrician within 2-3 days to check the jaundice again.

So what have I learned so far? Vast amounts of both normal and abnormal newborn physiology! I can't believe it's only been two weeks. Monday I start on the inpatient pediatric ward, which means that I will learn how to take care of sick kids. Monday is also my first call night - which means that I will be at the hospital from 6:30 am Monday until 2 pm Tuesday. If I am lucky, there will not be many admits over night and I may even get a few hours of sleep. This is what I have worried most about in going to medical school. How to survive a 30 hour shift without any sleep, and still make good medical decisions. Good thing that as a student I'm still mostly observing at this point. I'll let you know how it goes! Cheers!